Heart attack! Cutting the risk.

Heart Attack!

Santa Rosa, California, March 1989. The first warning came during a weekend outing. Phil was hiking up Mount Cobb; his little daughter, Carie, was riding contentedly on his broad shoulders. She was chatting distractedly to herself while making tufts and mats of her papa's hair. Rebecca, the energetic mother, climber steadily alongside her husband. An occasional cool breeze helped to soothe the perspiring foreheads of the husband and wife.

As Rebecca turned to admire her little family, she caught a glimpse of Phil's sudden wince of pain, the slowed pace, the hand pressed over the left side of his chest.

"You put Carie down right now, Phillip Edward Roth," she commanded with a shaky voice. "I'm taking you to the doctor as soon as we get home--and this time no excuses."

Stubborn as he was, Phil decided that this was not the best time to argue. A chill of fear swept over him. At 42 years of age, a dynamic manager with a national consulting firm, Phil approached eating, drinking, and work with great gusto--and oftentimes with excess. He readily admitted that his lifestyle was not the healthiest, but he didn't think it was so bad as to bring heart problems at this stage in his life.

Several clinical tests were required before it was determined that Phil had suffered a heart attack. Radical treatment reduced his chances of having another.

On any given day this year, almost 4,000 people in America will have a heart attack. One third of those attacks will be fatal.

Phil was lucky that day on Mount Cobb. He did not become a mortality statistic.

Old enemies, new plans. Cardiovascular disease affects more than 65 million Americans and was responsible for almost one half of all deaths recorded in the United States last year. Cardiovascular disease is not a single disease. It is a name that medical science uses to describe a group of related disorders. They encompass both common (hypertension) and more rare (congenital heart disease) pathologies that affect the intricate blood delivery system consisting of the "cardio" (heart pump) and the "vascular" (tubes, valves) components.

The principal enemies are well known--tobacco, high blood pressure, and excess cholesterol in the blood. In a new publication, Promoting

Health/Preventing Disease: Year 2000 Objectives for the Nation, the United States Public Health Service (USPHS) has prepared a blueprint for improving general health nationwide. Considerable time, money, and manpower are being dedicated to making Americans aware of cardiovascular risk factors. Efforts are being made also to provide new information and new strategies to help meet the USPHS objectives and address the challenge of changing lifestyles.

Cigarette strategy. USPHS objective: "Increase to at least 50 percent the proportion of current smokers age 20 and older who made a serious attempt to quit smoking during the preceding year, with one third of more of these attempts resulting in abstinence for at least three months."

Americans are increasingly concerned about how cigarette smoke affects their own health and that of their families. Breaking the cigarette habit, however, is not an easy affair for most people. In 1986, about 25 million smokers took major steps toward smoking cessation. Of these, one out of four became successful quitters, while the rest finally returned to smoking. Why the difference? Research comparing successful quitters versus "relapses" has brought to light some interesting new strategies for long-term success. For example, one of the most important factors related to success is the ex-smoker's skill in dealing with high risk situations (HRS).

The researchers discovered that successful quitters tend to have a clear strategy for coping with an HRS and use problem-solving skills, while relapses have poorly developed or no coping strategy and use mostly avoidance tactics. Oddly enough, smokers trying to quit do not expect to experience relapse crises, and thus many do not even attempt to cope with temptation. And coping response is better than none, but a clearly planned, appropriate, and well-practiced coping response promises the best chance of long-term success.

The following is a list of the most dangerous situations (HRS) wherein the ex-smoker will likely confront the strongest temptation to resume smoking:

1. Negative emotional states (such as frustration, anger, depression, interpersonal conflicts).

2. Social pressures (office, party, other smokers).

3. Alcohol and coffee consumption.

A good smoking cessation program should be able to provide the appropriate relapse prevention information and a professional environment to practice specific coping skills for each of the aforementioned areas.

One last secret for success: Siestas are good for smokers trying to quit. Smoking relapse usually occurs when ex-smokers are tired (especially in the afternoon and evening) and/or psychologically down. Therefore it would be profitable for most to take at least half an hour between 1:00 and 2:00 to relax completely.

Shaking off salt. USPHS objective: "Increase to at least 50 percent the proportion of households purchasing foods low in sodium, preparing foods without adding salt, and not adding salt at the table."

Unwittingly American's may be salting themselves to death. Every day the average American consumes between two and three times the amount required for the body's basic physiological needs. This excess salt habit increases the risk of hypertension, ultimately leading to cardiovascular disease--and death.

Table salt is actually 40 percent sodium and 60 percent chloride by weight. Thus, a teaspoon of salt (6 grams) contains 2.4 grams of sodium and 3.6 grams of chloride. It is the sodium component that is strongly implicated in blood pressure problems when it is taken in excess of the body's need.

As much as one third of our daily sodium intake comes from prepared foods such as sauces; TV dinners; cakes, cookies, and other desserts; cereals; and breads. Another one third occurs naturally in foods. The last third comes from the salty seasonings we add at the table. However, sodium is also found in such nonfood items as antacid tablets, antibiotics, laxatives, aspirin, and toothpaste.

The National Research Council recommends that individuals consume a total of no more than 2.4 grams of sodium, or about 6 grams of table salt (1 teaspoon) per day. Since the average American currently consumes 4 to 6 grams of sodium daily, this means that most Americans must take determined steps toward reducing their total salt intake by about 50 percent. Following the new decade diet, Americans must carefully choose from low-sodium-content foods at both supermarkets and restaurants (see Table 1).

Getting the family to reduce their salt intake is most easily accomplished when done in a progressive fashion. Subtract here a little, substitute there a little. Introduce some low- or no-sodium products in your home meals every couple of weeks. Explore health food stores for new brands. Bring a full and pleasurable taste to your meals with natural ingredients such as garlic, onion, cumin, lemon, and chopped walnuts. It is not recommended that a commercial salt substitute (potassium chloride, calcium chloride, or ammonium chloride) be frequently used. However, it may help some people who have a saltshaker habit.

Hypercholesterolemia: the fat connection. USPHS objective: "Reduce the mean serum cholesterol level for people age 20 and older to no more than 200 mg./dl."

Cholesterol is essential to life. We need it for building the complex chemical structures that drive our digestive processes, immune system, and sexual functions. Most of these needs are met by the liver, which is responsible for both cholesterol production and regulation. Another source of cholesterol is that which is found in the animal products used as food (cheeses, meats, lard). Too much of a good thing, however, is often fatal. Such is the case with cholesterol. Its excess tends to build up layers on the delicate walls of blood vessels, reducing the flow of vital nutrients and oxygen to energy-hungry organs. Serum cholesterol must be kept in line. Persons with blood cholesterol levels of greater than 250 mg./dl. have two times the risk of developing coronary heart disease. Persons with levels of 300 mg./dl. run three times the risk. Hence the USPHS's recommendation that serum cholesterol be no more than 200 mg./dl. Fortunately, much of this danger can be avoided by controlling how much fat a person allows to go into the body (diet) and onto the body (fat-muscle ratio).

Despite all the media hype, dietary cholesterol, in reality, makes only a very small contribution to the pool of cholesterol circulating in the blood. Saturated fat intake has a much bigger impact on serum cholesterol levels. Where a high intake of dietary cholesterol increases serum (blood cholesterol by a few milligrams per deciliter, a diet high in saturated fats increases cholesterol levels by as much as 40 to 50 mg./dl. Experiments have revealed that a diet composed of saturated fats (coconut, bacon, butter, oils) has twice the ability to raise serum cholesterol levels as a diet including polyunsaturated fats (saf-flower, corn, and soybean oils).

Total dietary fat must also be reduced if one wishes to dramatically lower one's serum cholesterol. The majority of health organizations recommend that dietary fats contribute no more than 30 percent of the daily calories consumed. Almost 90 percent of the dietary fats in the typical American diet comes from meats, cheeses, and packaged goods, while only 10 percent comes from legumes, grains, fruits, and vegetables. And since many Americans are addicted to the prepackaged dinners and fast foods, it is not hard to see why one in four of our citizens is overweight.

Finally, the body's ratio of fat to muscle is closely related to the level of cholesterol in the blood. On the average, each excess pound of fat tissue stimulates the liver to pump an extra 10 milligrams of cholesterol into the blood. The average person carries too much fat around (see Table 2). Chronic dieters are particularly at risk of slowly building fat stores and subsequently raising their serum cholesterol levels. During the fasting cycle they lose muscle and fat; however, during the eating cycle they typically put on fat without the muscle. Thus the ratio of fat to muscle becomes ever-increasing.

The good news is that this cycle is reversible. With some effort, the fat tissue can be decreased, and the muscle mass increased. The secret: strictly following a prudent diet (low total fat, high fiber, and complex carbohydrates), and regularly practicing endurance-type exercises (mountain biking, cross-country skiing, and long walks). These are the keys to increasing muscle mass and reducing fat tissue.

Serious about change. There is both science and art in helping people make lifestyle changes. And while there are many who claim expertise in such areas, pursuing charismatic programs that have more hype than substance most often result in wasted money and a disappointing experience. There are, however, highly qualified individuals who have been trained to smooth and shorten the path to making health a habit. Look for professionals such as dieticians, health psychologists, and Doctors of Health Science (D.H.Sc.), and those individuals bearing the title C.H.E.S. (certified health education specialist), issued by the Society of Public Health Educators.

Epilogue. Remember Phillip Roth? Ultimately he accepted his doctor's diagnosis, but he determined to fight the disease. Atherosclerosis is not only largely preventable but also reversible if the aforementioned health habits are practiced for a long term. Phil said to Rebecca, "This is the decade of change. People are taking charge of their destiny. From the fight for political freedom to the fight for a pollution-free planet, individuals are realizing that they can make an impact on their own lives. And I'm not going to become the victim of my own poorly managed lifestyle."

The barriers to a helath lifestyle are being broken down. The efforts of scientists worldwide have given both to a plethora of information, novel strategies, and new professional. Phil is right: this is the decade for change.

Jeff Gates, D.H.Sc., M.P.H., C.H.E.S., is a senior clinical data research specialist for a chemical firm in Geneva, Switzerland.